5= Very ready, I can do this! 4= Ready, but I have some concerns about implementing it 3= Somewhat ready 2= I don’t think I want to do this now but maybe in the future 1= Not ready
PERSONAL MEDICAL HISTORY
Medical Diagnosis Indicate any medical diagnosis, past or current
Medical Imaging & Testing
Medications & Supplements
Major stressors in the last year? Rate on a scale of 1-10 (10 being the most stressful)
Please indicate your average level of energy throughout the day using the scale 1-10 (1 is the lowest and 10 is the highest)
Alcohol, Tobacco, and Recreational Drug Use
Formal Sports (basketball, tennis, etc.)
REVIEW OF SYSTEMS
Do you have, or have you had within the past year, any of the following?
(Only females complete this section)
Gynecology and PAP History
(Only males complete this section)
3-Day Food Diary and Instructions
It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.
Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits.
Record information as soon as possible after the food has been consumed
Describe the food or beverage as accurately as possible e.g., milk - what kind? (whole, 2%, nonfat); toast (whole wheat, white, buttered); chicken (fried, baked, breaded); coffee (decaffeinated with sugar and 1/2 & 1/2).
Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.
Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.
Include any additional comments about your eating habits on this form (ex. craving sweet, skipped meal and why, when the meal was at a restaurant, etc.)
Please note all bowel movements and their consistency (regular, loose, firm, etc.)